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The successful management of the hospitalized older adult will incorporate features of effective models of care described above. A common feature of these models is the recognition that the care plan must be consistent with the patient’s goals of care. Failure to understand a patient’s goals of care is common, and can lead to frustration and dissatisfaction on the parts of patients, family members, and caregivers.
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The goals of hospital care should be established upon admission for each patient. For older persons, these can vary widely and may include prolonging survival, relieving specific symptoms, maintaining or regaining ability to walk or care for oneself, getting help taking care of oneself, avoiding institutionalization, being reassured during a frightful experience, and providing comfort and peace while dying. Family members may share these goals but may also have additional goals, such as getting help caring for the patient, facilitating a transition in care from home to long-term care, or being protected from a frightening situation. Physicians and other professionals involved in the care of the patient may share these goals and also aim to achieve quality, efficiency, and patient satisfaction measures for inpatients, reduce hospital costs, and avoid adverse events.
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Such discussions may be initiated with open-ended requests, such as: “Different patients have different goals when they are admitted to the hospital. Can you tell me about what you would like us to accomplish while you are in the hospital?” Discussions of goals of care are broader than simply cataloging do-not-resuscitate (DNR) decisions or reviewing options for specific therapeutic interventions. In fact, DNR and other decisions may be ill-informed without discussion of the goals of care. Explicit articulation of goals of care will sometimes identify disagreements or unreasonable expectations, which should be recognized and usually addressed.
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Comprehensive Geriatric Assessment
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A second feature of these models is the addition of a comprehensive assessment of a patient’s physical, cognitive, psychological, and social functioning to the problem-focused assessment (Table 16–1). The problem-focused assessment will identify and address the reason for admission. The comprehensive assessment of key functional domains will ensure that an appropriate care plan is implemented. Just as the underlying reasons for the hospitalization of an older adult may be multifactorial, the care plan must address these multiple factors.
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Functional assessment determines the patient’s ability to walk and to perform basic ADLs (eg, bathing, dressing, transferring from a bed to a chair, using the toilet, self-feeding) both at baseline, before onset of the acute illness, and on admission. For some patients, an unmet need for assistance with ADLs at baseline may be a contributing factor to the hospitalization. Patients who are dependent in an activity of daily living on admission have longer hospitalizations, higher risk for additional ADL dependence at discharge, and higher risk for death on average than otherwise similar patients who are independent in ADL. Patients dependent in ADLs at discharge are at increased risk for nursing home placement, loss of additional ADLs after discharge, and for death during the next year. Past history of falls is also important to elicit on admission and address during the hospitalization and in collaboration with the primary care provider after discharge.
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Cognitive and psychological assessment should include assessment of mental status and affect. Among hospitalized older medical patients, ≥20% have dementia, ≥15% are delirious on admission, and another 15% experience delirium during hospitalization. Symptoms of depression are common, and 33% of hospitalized older medical patients have major or minor depression.
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Neuropsychiatric assessment begins on meeting the patient. Stop to consider the possibility of dementia, delirium, and depression: They are frequently present but infrequently reported. To whom are you speaking? If you are obtaining the history from a surrogate rather than the patient, cognitive impairment from dementia or delirium or both is likely. Serious cognitive impairment is indicated by an inability to recall any of 3 items; it is largely ruled out by recall of 3 items and ability to draw the face of a clock as in the Mini-Cog. Listen for evidence of any change in mental status or behavior, and watch for signs of impaired thinking, speech, or judgment. The presence of fluctuating mental state, impaired attention, and/or consciousness or disorganized thinking suggests a delirium. Evidence of inattention includes difficulty focusing, being easily distracted, or failure to repeat 5 digits. The Confusion Assessment Method (CAM) is a highly sensitive and specific screening tool for delirium in hospitalized older adults. As a simple screen for depression, ask the patient whether he or she has felt sad, depressed, or hopeless over the last month.
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It is critical for the attending physician, along with other members of the interprofessional team, to understand the patient’s social context in order to develop an effective after hospital care plan. Social isolation, loneliness, and lack of social supports are common in hospitalized older adults. This will affect the amount of in-home supportive services, meals and transportation assistance, and assistive devices a patient may require. Any hesitations or concerns should be explored further for evidence of elder neglect or abuse. The prevalence of elder abuse is higher in hospitalized settings (∼14%) than in the general community (∼3% to 4%). Ask about how the patient manages his or her finances to explore for evidence of financial abuse. Concerns about abuse should be discussed with a social worker and reported to the local adult protective services agency.
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In addition to completing a functional, cognitive, psychological, and social assessment on every older adult admitted to the hospital, a geriatrics-focused review of systems may identify conditions that are commonly considered geriatric syndromes, including incontinence, falls, sensory impairment, undernutrition, and social isolation. Each of these conditions can and should be addressed specifically. In addition, however, it is important to recognize that frequently 2 or more geriatric syndromes occur synchronously in frail patients, and that the burden of this frailty on patients, families, and professionals is substantial.
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Interprofessional Care
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The third common feature of many successful models of care for older adults is an interprofessional approach that addresses the multiple factors that may contribute to hospitalization. In most cases, designing and implementing strategies to achieve the goals of care requires the physician’s expertise and the expertise of a team of other experts. For example, consider the situation of an 83-year-old widow with chronic obstructive pulmonary disease (COPD) and mild cognitive impairment who lives alone, has declined over the past month in her ability to take care of her home and her affairs, is admitted with hypoxia and hypercarbia attributed to a COPD exacerbation, and wishes to live in her home until she dies. Although the physician may have the expertise to treat the COPD exacerbation, nursing, social work, and occupational therapy expertise is also required to promote the patient’s independent function at home after discharge.